Richard Joseph, MD, is an assistant professor of medicine/oncology at Mayo Clinic. His Hematology/Oncology fellowship was completed at MD Anderson Cancer Center. He is a voting member of the NCCN (National Comprehensive Cancer Network. He belongs to Melanoma International’s Scientific Advisory Board and received MIF’s Doctor of the Year award for 2015.
» KEYTRUDA VS. OPDIVO
Is one Pd1 better than another for response rates? My doctor wants to switch me from Keytruda to Opdivo to see if I get a better response. Is there any evidence out there? Should I do it? My disease is definitely growing.
Dr. Joseph: “The response rates of Keytruda and Opdivo are very similar in trials with a RECIST response of ~40%, when used in the front line and closer to ~30%, when used in the second line or beyond. So, while a randomized study has never been performed to prospectively compare Opidivo and Keytruda, most oncologists feel these drugs are equivalent in efficacy and toxicity. In terms of switching from Keytruda to Opdivo, there is no data that I’m aware of to support this. I would consider alternative treatments including a clinical trial for patients who have progressed on anti-PD1.”
NOTE: RECIST criteria means Response Evaluation Criteria In Solid Tumors (RECIST) is a set of published rules that define when tumors in cancer patients improve (“respond”), stay the same (“stabilize”), or worsen (“progress”) during treatment.
» GOING OFF KEYTRUDA
I am NED after nearly going into hospice with widespread disease and now have been on Keytruda for 9 months. I have decided to go off of it and my doctor says it is okay. Do you think this is a safe path? I feel I can just go back on it if I have progression of disease.
Dr. Joseph: “This is a very important question without a great answer at present. My opinion is that once a patient has a nice response to Keytruda, additional doses may not be necessary. Hopefully prospective trials will look exactly at this question so we can all figure out how much immunotherapy is enough. I also agree that if you disease were to resume growth, there is some data to support it will respond upon resuming the Keytruda. “
» PRE-EXISTING CONDITIONS
I have an auto-immune disease (lupus) pre-existing to my melanoma, can I go on PD1 or will I have issues. My doctor is unsure. He feels that IPI is definitely not in my cards but PD1 might be okay?
Dr. Joseph: “Another great question with not a lot of data to guide us. There are many reports out there of patients trying anti-PD1 or anti-CTLA4 agents with a history of auto-immune disorders and the results are mixed. At this point, I think it is too soon to know how safe the drugs are in the setting of auto-immunity. When pressed to make these decisions, I review with the patient the pros and cons of trying immunotherapy and together we make a decision. I do think if anti-PD1 causes an auto-immune flare, this can likely be reversed with immunosuppressants. “
My disease seems to be gone, but I have side effects from the Keytruda of exhaustion, leg pain and chest pain. What can I do to alleviate these?
Dr. Joseph: “I see this quite often. I’ve had mixed success with low dose steroids in relieving a lot of these symptoms with a plan then to continue tapering down the steroids. In addition, I would encourage your physician to look for a possible thyroid or adrenal disorder that might be causing these symptoms.”
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